The major mechanism is all the monogenic hypertension forms is the retention of sodium, which increases the blood pressure. Therefore, one primary and local way of treating hypertension is to increase urinary sodium excretion. Among the three types of diuretics drugs, thiazide is rated as being in the first line antihypertensive options. Randomized meta-analyses and control trials have shown that when compared to other methods like no treatment or placebo, there are significant reductions in the blood pressure levels when these antihypertensive drugs are used, which is also accompanied by reduced stroke and other major cardiovascular events. It is complex to understand the role played by diuretics in hypertension treatment since, in other countries, these drugs are blended with different sets of drugs and are not used alone as first-line anti-hypertension therapy. Moreover, there is a continued increase in the emphasis of single-pill combination and combination treatment guidelines. Additionally, thiazide-like and thiazide diuretics have historically been generally grouped under 'thiazide.'
The article reaffirms the place of diuretics in comorbidities and hypertension, looking at the first-line treatment in guidelines, type 2 diabetes mellitus, elderly, history of stroke, Salt-sensitive, and low-renin hypertension, and black patients of African or Caribbean descent (Burnier, Bakris & Williams, 2019). Throughout the world, diuretics are listed by guidelines as the first-line treatment for essential hypertension. That is because many patients have the potential of benefiting from diuretics due to its ability to counter the extracellular volume expansion and hypertension-associated salt retention, and reduced mortality and morbidity. For patients living with diabetes mellitus, especially kidney disease, the first-line treatment is that of the renin-angiotensin system (RAS). Nevertheless, since diabetic patients are at significant risk of developing renal impairment or heart failure and are prone to fluid retention, they are likely to benefit from natriuresis provided by diuretics, though some of them may have side effects on metabolic parameters. For the elderly who are above 65 years, they are at higher risks of having electrolyte imbalances since they often take multiple medications (Burnier, Bakris & Williams, 2019). Diuretics are listed by the Latin American Society of Hypertension guidelines as the preferred first-line treatment due to its strong indapamide and chlorthalidone data. There is further support for the value of therapy with chlorthalidone by ALLHAT sub-analysis in patients not less than 65 years of age.
The article also highlights studies that underscore the significance of treating patients having a history of stroke with diuretics. According to the article, the Latin American Society of Hypertension, it recommended the use of indapamide sustained release combined with an ACE inhibitor. Such recommendations are based on data acquired from two trials on patients with transient ischemic attack or stroke history. For black patients in monotherapy, the use of thiazide-like diuretics is recommended as first-line treatment. According to the article, several studies support that such medications are efficient for this given population since compared to lisinopril treatment, most of them are lower with chlorthalidone treatment.
The article also looks at some of the factors considered when selecting thiazide-like diuretics over thiazide diuretics. The use of thiazide-like diuretics is preferred to that of thiazide, and it is recommended by the 2018 ESC/ESH hypertension guidelines (Burnier, Bakris & Williams, 2019). Their duration of action is the primary reason behind such decisions, its long-term cardiovascular endpoint reduction, and the ability to lower high blood pressure. The effects of thiazide and thiazide-like diuretics are traditionally considered to be the same. Still, there is a difference when the analysis is done on their action speed, dose-response, and potency. Thiazide-like diuretics also have higher tolerability, and for every three molecules, the effects on metabolic parameters and serum potassium have been shown to depend on the dose. Thiazide-like diuretics can be prescribed at lower levels to reduce the treatment impact on laboratory parameters with the blood pressure reduction not being jeopardized.
The article also touches on vascular health and end-organ damage by the diuretics. High blood pressure has significantly reduced due to the improvements in clinical endpoints. Markers of cardiovascular health and renal function has improved due to the first-line therapy classes of drugs, but considering the vascular health and end-organ damages that are not driven by the reduction in high blood pressure are considered, differences start to appear not only between drug classes but also between drugs that belong to the same therapeutic class. According to the article, there are favorable changes in the markers of renal hemodynamics and renal injury that are significantly greater in the losartan/indapamide group as compared to losartan/HCTZ (Burnier, Bakris & Williams, 2019). The effects that are independent of blood pressure are the possible contributors to the variances in thiazide-like and thiazide diuretics.
Thiazide-like diuretics have been proven to be effective in reducing hypertension. The diuretics minimize the volume of plasma by increasing water and sodium excretion (Thorn, Ellison, Turner, Altman & Klein, 2013). In the first stages, this reduces carbon monoxide hence reducing blood pressure. The volume of extracellular fluid and carbon monoxide returns towards normal with time; there, the effects on hypertension persists due to the reduced peripheral resistance. The use of longer-acting thiazide-like diuretics like chlorthalidone is usually superior compared to shorter-acting hydrochlorothiazide when used in preventing some hypertension effects such as renal and cardiovascular effects (Thorn et al., 2013).
Burnier, M., Bakris, G., & Williams, B. (2019). Redefining diuretics use in hypertension: why select a thiazide-like diuretic?. Journal of hypertension, 37(8), 1574-1586. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6615933/
Thorn, C. F., Ellison, D. H., Turner, S. T., Altman, R. B., & Klein, T. E. (2013). PharmGKB summary: diuretics pathway, pharmacodynamics. Pharmacogenetics and genomics, 23(8), 449. ncbi.nlm.nih.gov/pmc/articles/PMC4084786/
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